Essential surgery: key messages from Disease Control Priorities, 3rd edition

Overview

This report synthesises the main results of the individual chapters of Essential Surgery to provide broad directions for policy. The key messages deriving from our analysis are summarised and explained in further detail below, concerning five categories of results: surgically avertable disease burden, cost-effectiveness and economics, improvements to access, improvements to quality, and essential surgery in the context of universal health coverage. The appendix lists the titles, authors, and main messages of each individual chapter of Essential Surgery.

Disease burden avertable by essential surgery

The disorders treated at least partly by the procedures in table 1 account for 4·7 million deaths (or 10% of all deaths) in low-income and middle-income countries (table 2). This figure is probably an underestimate, because the burden of several common surgical disorders represented in table 1 (eg, bowel obstruction and gallbladder disease) are not estimated as distinct entities in WHO’s Global Health Estimates and hence are not included in table 2. With universal coverage of essential surgery in low-income and middle-income countries, 1·5 million deaths per year could be averted (table 3), representing 6·5% of all avertable deaths in these countries.

By comparison, DCP2 previously estimated that 11% of the total global burden of death and disability was from disorders that were very likely to need surgery.^15,16 The current estimates are based on a more rigorous estimation method and a more narrowly defined subset of essential surgical disorders (figure 1), excluding other highly prevalent disorders often treated by surgery (eg, cancer and vascular disease). Further details about the estimation of burden avertable by essential surgery are provided in panel 1.

Obtaining more accurate estimates of avertable burden from surgically treatable disorders will need broad agreement on a definition of the concept of avertable burden and on methods for its measurement. The steps taken in Essential Surgery should be regarded as preliminary. Improved estimates of avertable burden will need systematic data gathering from hospitals and population-based surveys to establish the proportion of the world’s population that lacks access to surgical care. Such a survey was recently done in Sierra Leone,¹⁷ showing that 25% of deaths might have been prevented with timely surgical care. Similar studies need to be repeated more widely. In addition to individual research studies, the international community could contribute to development and promotion of metrics for ongoing monitoring of the burden of essential surgical disorders, as is currently done for maternal mortality.

Economic evaluation of essential surgery

At the time of DCP2, a small number of cost-effectiveness analyses had shown specific surgical procedures to be very cost effective. Since then, the scientific literature has expanded and consistently documented that many of the essential surgical services identified in this report rank among health care’s most cost-effective interventions (figure 2). A few examples (all context specific) include cleft lip repair (US$10–110 per disability-adjusted life-year [DALY] averted), inguinal hernia repair ($10–100 per DALY averted), cataract surgery (about $50 per DALY averted), and emergency caesarean section ($15–380 per DALY averted). By comparison, many of the widely disseminated public health measures are of similar cost-effectiveness, for example vitamin A supplementation (about $10 per DALY averted), oral rehydration solution (more than $1000 per DALY averted), and antiretroviral therapy for HIV/AIDS (about $900 per DALY averted).^19,20

Benefit–cost analyses have shown similar findings. An analysis of the benefits from cleft lip repair evaluated the costs needed to run a specialised cleft clinic in India and the resulting health benefits, to which a monetary benefit was ascribed. Cleft surgery had a cost of about $300 per DALY averted and had a benefit–cost ratio of 12:1.²¹ This puts cleft repair within the benefit–cost ratio range for the key investment priorities for disease control established by the Copenhagen Consensus, an organisation that asks experts to rank global health and development interventions.²² The benefit–cost ratio for cleft surgery is also very high, similar to the range across different development sectors. Panel 2 provides an overview of approaches to economic evaluation of surgical procedures and an overview of findings.

The cost-effectiveness of some platforms or facility-types for provision of surgical care also needs to be considered. Essential Surgery includes a chapter on cost-effectiveness analysis.¹⁸ Basic essential procedures are likely to be cost effective when delivered at any level of the health-care system. However, the first-level hospital has been found to be especially cost effective as a surgical delivery platform, with costs of $10–220 per DALY averted for all surgical care delivered in this setting, across a wide range of low-income and middle-income countries.^4,26–28 Most surgery in the first-level hospital is emergency surgery. Therefore, health systems need to disperse surgical facilities widely in the population, and surgical teams working in first-level hospitals should have a broad array of basic emergency skills rather than a narrow range of specialised skills.

A range of other surgical platforms were considered in our analysis. Short-term surgical missions by outside surgeons (ie, surgeons not living and working in that area) seem beneficial only if no other option is available; otherwise suboptimum outcomes, unfavourable cost-effectiveness, and lack of sustainability reduce their usefulness. Self-contained mobile platforms, such as hospital ships, seem to offer good outcomes for people who can reach them, but there are no data about their cost-effectiveness and obvious limitations for scale-up and national ownership. Specialised hospitals, including those providing surgery for cataract and obstetric fistula, seem to be among the most cost effective of the competing options for specialised platforms.²⁹ Such specialised hospitals would be most sustainable if they also developed strong links with local practitioners (ie, those living and working in that country) to promote training and to ensure appropriate postsurgical care, and eventually evolved to be led by these local professionals. Because essential procedures done in specialised hospitals are elective, not urgent, patients can be scheduled over space and time to achieve high volumes, contain costs, and improve technical quality.

Many people with surgical disorders, especially trauma, die in the prehospital setting. For example, findings from a study³⁰ showed that 81% of trauma deaths in Kumasi, Ghana, were in the prehospital setting. Most prehospital deaths occur in areas of low-income and middle-income countries where formal emergency medical services are rudimentary or absent. Improvement in the first aid skills of lay first responders can cost less than $10 per year of life gained, making it one of the most cost effective of all health interventions. Likewise, basic ambulance services can cost less than $300 per year of life gained, which is still highly cost effective.³¹

In 2013, Jamison and colleagues²² estimated that it would cost just over $3 billion annually to scale-up delivery of the component of the essential surgery package shown in table 1 that is applicable to first-level hospitals, so that this package is available universally. This development would have a benefit–cost ratio of 10:1, which is broadly consistent with that of other surgical procedures as described by Alkire and colleagues.²¹

Measures to improve access

The substantial avertable burden from surgical disorders is directly related to the low capacity for surgical care in many low-income and middle-income countries, as shown in the numbers of surgical procedures done globally. Most operations (60%) take place in wealthier countries, where 15% of the world’s population lives. Only 3·5% of operations take place in poorer countries, where 35% of the world’s people live.³² This low capacity for surgery in low-income and middle-income countries is in turn related to shortages of both human resources (eg, skills and staffing) and physical resources (eg, equipment and supplies).

In terms of human resources, across 23 low-income and middle-income countries the ratio of general surgeons per population was shown to range from 0·13 to 1·57 per 100 000, whereas the ratio of anaesthesiologists per population ranged from 0 to 4·9 per 100 000.³³ By contrast, the USA has nine general surgeons and 11·4 anaesthesiologists per 100 000.³⁴ There are also striking differences in the ratio of operating theatres per population across high-income and low-income settings: 25 per 100 000 in eastern Europe, 14–15 in North America and western Europe, 4–14 in Latin America, 4·7 in east Asia, but just 1·3 in south Asia and 1–1·2 in sub-Saharan Africa.²

There are examples of institutions and health systems successfully overcoming these barriers. For example, establishment of the Ghana College of Physicians and Surgeons in 2003 created the first in-country credentialing process for surgeons and led to an expansion of the workforce of fully trained general surgeons and obstetricians. As of June, 2014, 284 specialist surgeons and obstetrician-gynaecologists have graduated from the College and been posted to regional and district hospitals throughout the country to serve as both providers and trainers.

Expansion of access to essential surgical services in rural areas of low-income and middle-income countries will probably be impossible in the foreseeable future with dependence on only fully certified surgeons and anaesthesiologists. Innovative solutions to the surgical workforce crisis are thus imperative. Evidence shows that midlevel operators can safely do several essential surgical procedures, provided that they are properly trained and supervised and perform the operations frequently.^35,36 In some locations these operators are general practitioners. In other areas, they are non-physician clinicians, such as técnicos de cirurgia in Mozambique or assistant medical officers in Tanzania.

Outcomes such as maternal and neonatal mortality after caesarean section and other emergency obstetric procedures for assistant medical officers were similar to those of doctors in Tanzania.^35,36 Although cost studies are few, preliminary evidence shows the cost-effectiveness of task sharing. For example, in Mozambique, it was three times more cost effective to train and deploy técnicos de cirurgia than to train and deploy physicians to provide obstetric surgery; the 30-year cost per major operation was about $40 for técnicos de cirurgia and about $140 for physicians.³⁷ Likewise, emergency obstetric care provided by general practitioners was found to be more cost effective than that provided by fully trained obstetricians in Burkina Faso.³⁸

Non-physician clinicians are more likely than physicians to stay in under-served rural areas, and are less likely to emigrate to other countries; their deployment therefore substantially increases the availability of surgical services in under-served rural areas. In Mozambique and Tanzania, non-physician clinicians do about 90% of major emergency obstetric surgeries in rural areas where most of the population live, as explained in more detail in the DCP3 chapter on workforce innovations.³⁹ Challenges continue for many countries in terms of physicians’ acceptance of non-physician clinicians, standardisation of their training, supervision, regulatory mechanisms, continuing skills improvement, and remuneration as well as non-financial incentives. The long-range goal is expansion of the number of fully trained surgeons. However, general practitioners and non-physician clinicians, with appropriate support from surgeons, can be an important intermediate solution to the problem of access to basic surgery.

Surgical training has traditionally emphasised decision making and operative technique for individual patient care, which is appropriate in view of the clinical role that most surgeons have. However, those surgeons who wish to address the system-level barriers to achievement of universal coverage of essential surgery will need additional skills in management and supervision of health-care systems, quality improvement, and public health.

In terms of physical resources, two related WHO efforts have defined optimum infrastructure needs for first-level hospitals for surgical care generally (the WHO Programme for Emergency and Essential Surgical Care) and for trauma care at all levels of the health-care system (the Essential Trauma Care Project). Surveys done with these WHO guidelines and tools have shown consistent lack of many low-cost pieces of equipment and supplies (eg, chest tubes, oxygen, and equipment for airway management and anaesthesia) in many locations, but especially in low-income countries and at first-level hospitals. In some cases, items are physically present but non-functional—for instance, equipment awaiting repairs. Often equipment is functional, but available only to those who can pay, sometimes in advance, and thus many patients who need the services are unable to access them.^6,13,40–46

As with human resources, there are examples of health systems successfully confronting these barriers. For example, the Hanoi Health Department, Vietnam, steadily improved its physical resources for trauma care in its network of clinics and hospitals. Such improvements have been stimulated partly by research defining substantial gaps in availability of low-cost items recommended in WHO’s Guidelines for Essential Trauma Care, and by advocacy to remedy those gaps.^47,48

Many essential physical resources are low cost and could be better supplied through improved planning and logistics. However, availability of some of the more expensive items (eg, x-ray machines, ventilators) would be improved by research into product development. Such research should address improved durability, low cost (both for purchase and operation), and increased ease of operation. Likewise, availability of many items could be improved by increased capabilities for local manufacture.^49,50 However, international assistance for provision of basic essential equipment and supplies will be needed for the immediate future for the poorest countries. An often-overlooked component is the need to ensure local capacity to maintain and repair equipment.

For both human and physical resources, population, policy, and implementation research could contribute by identifying more-efficient and lower-cost delivery methods. WHO has already made substantial contributions by establishing norms for human and physical resources for surgical and trauma care and by documenting success stories of individual countries,^6,13,47 a role that should be expanded.

A large additional barrier to access to surgical care is financial, especially in situations in which user fees are high or where out-of-pocket payments are required. Cost of surgical care is also a substantial contributor to medical impoverishment, as explained in more detail in the DCP3 chapter on surgery and poverty.⁵¹ Inclusion of universal coverage of essential surgery within universal public finance would remove financial barriers to access to essential surgical care, and would offer financial risk protection, as discussed further at the end of this report.

Improving the safety and quality of surgery and anaesthesia

In all settings, surgical care is fraught with hazards, including risks from the diseases themselves, from the operation, and from anaesthesia. These hazards translate into strikingly different risks of death and other complications in different settings. For example, compared with Sweden’s rate of 0·04 deaths per 1000 caesarean sections, mortality is at least 2–4 times higher in Latin America, 6–10 times higher in South Asia, and 100 times higher in sub-Saharan Africa.^52,53

A large component of the differences in mortality after operations is caused by differences in mortality due to anaesthesia. Major advances have occurred in anaesthesia safety in high-income countries, mainly as a result of improved monitoring and increased standardisation and professionalisation. In wealthier countries, mortality per million anaesthetics has decreased from 357 deaths per million before 1970 to 25 deaths per million in the 1990s and 2000s. However, high rates of anaesthetic deaths are still prevalent in most low-income and middle-income countries. Deaths solely attributable to anaesthesia are estimated to occur at a rate of 141 deaths per million anaesthetics in poorer countries, by comparison with the noted 25 deaths per million anaesthetics in wealthier countries.⁵⁴

Many of the deaths and complications from surgery in low-income and middle-income countries are potentially preventable with three specific affordable and sustainable improvements: use of a surgical safety checklist, improved monitoring and related safety practices during anaesthesia, and improved systems-wide monitoring and assessment of surgical care overall.

Use of the simple, 19-item WHO Surgical Safety Checklist across eight countries was reported to double adherence to basic perioperative safety standards,^55,56 such as confirmation of the procedure and operative site, objective airway assessment, and completion of instrument and sponge counts at the end of the procedure. Use of the checklist reduced deaths by 47% (the postoperative death rate fell from 1·5% before introduction of the checklist to 0·8% afterwards) and inpatient complications by 35% (from 11% to 7%). The checklist improved outcomes in high-income, middle-income, and low-income countries and in elective and emergency cases.

The safety of anaesthesia in high-income countries has been achieved through adoption of standards of care, such as continuous presence of a trained anaesthesia provider and uninterrupted monitoring of oxygenation, ventilation, and perfusion.⁵⁷ Anaesthesia delivery systems have been better standardised with safety features engineered into the machines. One crucial technology is pulse oximetry, an essential standard in high-income countries, which allows ongoing monitoring of oxygenation status so that problems can be corrected early on, before they lead to serious or lethal consequences. In one study in Moldova,⁵⁸ introduction of a surgical safety checklist and pulse oximetry cut the number of hypoxic episodes and the complication rate by more than half. A barrier to pulse oximetry availability has been its cost, although a concerted global effort is underway to reduce these costs and increase availability of pulse oximetry in low-income and middle-income countries. With lower-cost options now available, the cost-effectiveness of pulse oximetry introduction seems very favourable.⁵⁹

Improved monitoring and evaluation of surgical care across institutions, such as through quality improvement programmes, help to better inform administration and management. Quality improvement programmes range from very simple outcome assessments (eg, morbidity and mortality conferences) to more complex monitoring, such as surveillance of complications and use of risk-adjusted mortality. Many hospitals in low-income and middle-income countries have some type of basic quality improvement activities, such as periodic morbidity and mortality conferences. The effectiveness of these activities could be increased by simple measures such as more systematic recording of proceedings, more purposeful enactment of corrective action, and monitoring of the outcome of this corrective action. A WHO review of quality improvement programmes for trauma care showed that most programmes led to improvements in patient outcomes (including mortality) or process of care, with some centres also reporting cost savings.⁶⁰ Although most of the programmes were from high-income countries, two were from Thailand, where a model programme for quality improvement led to sustained improvements in both process of care and mortality. Despite their effectiveness, simplicity, and affordability, quality improvement programmes are at a very rudimentary level of development and implementation in most low-income and middle-income countries.^41,60

An important role for the international community is to support population, policy, and implementation research that addresses affordable and sustainable methods to improve quality of care, and documents and disseminates specific case studies of good practices being sustained.²³ WHO has already made substantial contributions by establishing norms such as the WHO Surgical Safety Checklist. This role needs to be expanded further, such as through establishment and promotion of standards for safe, low-cost anaesthesia machines, and norms for monitoring and evaluation of procedures for surgical care. There also needs to be better definition and tracking of a variety of quality indicators globally, such as the perioperative mortality rate.^54,61,62

Surgery as a core component of universal health coverage

Our results point to the potential for essential surgery to cost-effectively address a large burden of disease. Moreover, there are several viable short-term and longer-term options for improvement of access, safety, and quality of surgical care. Figure 3 shows alternative uses for incremental resources in light of these findings. A country’s situation today could be portrayed as a point in the cube: its position on dimension Q depicts the current average quality of care, its position on dimension A represents the proportion of the population with access to care, and its position on dimension R shows the range of services available. Investment choice requires assessment of whether to put incremental money into improvements in access, improvements in average quality, or improvements in the range of services to be offered. Our interpretation is that it will generally prove both equitable and effcient to achieve full access to essential surgery at high quality rather than committing public resources to expanding the range of services for a smaller proportion of the population. The shading in figure 3 depicts this situation, which we have labelled universal coverage of essential surgery. Achievement of universal coverage of essential surgery should appear early on the pathway to universal health coverage as discussed by Jamison and colleagues.²³

There are other surgical disorders and procedures to consider, such as those for cancer, vascular disease, and disorders requiring more advanced treatments such as transplantation. Improving access to these procedures will also have benefit. But, in terms of sequencing and use of public funds, efforts to assure greater access to quality essential services should be undertaken before increased investment in disorders that are more expensive to treat or that have a smaller health effect.